Are we there yet? Reaching global goals for HIV in Asia and Pacific Regions

Treatment approaches should also be within context of a country’s culture. Any approaches for it to work must be culturally appropriate. HIV and drug use are indeed global issues but unfortunately, successful approaches in first world countries does not automatically translate to the same level of success in third world countries. Take the Philippines as an example. MSM is an issue that is still taboo in many places, particularly in very remote places; therefore, collecting accurate data will remain questionable. Studies will always be one sided for not all views will be collected. Drug program and HIV intervention as mentioned, are treated separately for the reason stated above. Are we there yet? Certainly not. But until culturally appropriate treatment strategies could be devised, HIV will always remain a stigma and the 90-90-90 target will remain a long way from achievement.

Maria gave a disturbing presentation about the current state of HIV prevention work in the Philippines. There has been a frightening shift in the landscape since President Duarte took the reins in June 2016.

Between 2010 and 2016 the Philippines has seen a doubling of HIV infections from 4300 to 10500. Maria noted that prior to that time progress on HIV prevention in the Philippines was “low and slow”. While most of the rise is seen to be amongst young MSM, there is also concern for those who inject drugs. Prevention for this group under the current Government will be very difficult.

After taking office President Duterte declared a ‘war on drugs’ , which has been marked by harsh condemnation of drug users and Presidential ‘permission’ to punish and kill drug users. Maria presented several quotes from the president, which including the words “free to kill idiots” (IV drug users). The impact on the ground was the beginning of extra judicial killings which have led to an estimated 13000 deaths. Maria described this as a “shoot first, ask questions later” approach.

She noted that the political message represented a harnessing of fear and social discontent, with its roots in social inequality. It has enabled the institutionalisation of fear through promises of cleaning up society. Maria argued that for Duterte it has led to a consolidation of political support.

The resulting discrimination means that drug users have been driven further into the shadows, with people avoiding health care because they fear for their safety. Harm reduction has become much more difficult. Programs such as clean needle distribution have been discontinued, drug use is poorly documented, and activists/advocates are afraid to get involved.

Drug use and HIV interventions are treated separately, so there is no cross linking.

The situation in prisons is very concerning, with greater overcrowding and a subsequent rise in health issues, which is likely to include blood borne infections.

Overall it appeared to be a grim picture which does not present much room for optimism, however Maria discussed some areas of hope. While dialogue is not possible nationally, change may be initiated at the community level. Some communities and smaller organisations are stepping in to help despite the risks.

IV drug users have the most to fear in the current climate. Perhaps Australian health workers and their peak bodies can find ways to support those communities which are brave enough to help people affected by these depressing government policies, and through this keep alight the flame for HIV prevention.

An interesting discussion around whether key populations are being reached in terms of the HIV response within Papua New Guinea (PNG).

Dr Kelly-Hanku explained we need to ‘unpack’ the term key population and posed the question of exactly ‘who’ are the key populations.

Sexual identity: How one claims their sexual identity is changing in PNG. From bisexual to gay to men who have sex with men (MSM), to men of diverse sexualities.

Attraction: Who one is attracted to; only women, only men or mostly women for example, however this does not mean they are having sex with who they are attracted to.

Sexual behaviour: Who did they last have sex with? Male, female and so on.

These complexities around sexual identity may indeed be the reason why some key populations are not being reached in PNG, claiming the picture is far more complicated than people wanted to know.

Dr Kelly-Hanku suggests we learn how to work with it, through the different layers of diversity, attraction and ethnicity. Much more work needs to be done in order to reach the global targets for HIV and increase levels of testing and treatment, however PNG is up for the challenge, showing it can be done, where some financial donors have said no!

]]>r.bosworth@unsw.edu.au (Rebecca Bosworth)Global issues, HIV in developing settingWed, 08 Nov 2017 20:18:31 +1100HIV Response in PNG. Are key populations being reached?http://ashm.info/global-issues-hiv-in-developing-setting/hiv-response-in-png-are-key-populations-being-reached
http://ashm.info/global-issues-hiv-in-developing-setting/hiv-response-in-png-are-key-populations-being-reachedPerhaps one of the more applicable talks to my experience in Timor was that given by Angela Kelly-hanku on challenges reaching key populations.

In PNG its the church groups who often provide the most stable centers to operate health interventions (different from in Timor), and these have been the platforms from which international health programs have carried out their work.

The talk highlighted just how difficult it is to define the 'key populations', in that many who present to these facilities do so as they want non-judgmental care, where they won't be labelled as MSM, FSW and so on. I do wonder if its similar to the situation in Timor, where the largest HIV clinic is run by a private NGO, as foreign staff (and possibly church groups) are less likely to know the patient and their family. But defining key population can be so much more difficult... An interesting chart revealed 20% of MSM in PNG didn't report being attracted to men, and 40% reported being attracted to both men and women. We may see a fairly similar pattern in Timor once again, where a high percentage of the MSM (>50%) also have female partners. This could be related to the horrendous level of stigma and discrimination against them.

However the ultimate answer to the question are we reaching the key populations was revealed towards the end of the presentation with confronting statistics revealing 60% of the MSM in PNG have never been tested, and 32% of the FSW have never been tested. So No is the answer.

I can't imagine Timor is any better with the horrendous supply chain issues encountered over the past year...

The focus of this session was to discuss how our neighbours are meeting global goals for HIV, in terms of leaving no one behind in the aids epidemic.

The ongoing fight to end the public health threat of AIDS concerns all of us. The epidemic does not respect borders, whether it be new migrants that have acquired AIDS overseas and settle in Australia or tourists visiting overseas and returning with an acquired infection.

The Philippines in particular has one of the most explosive HIV epidemics in the Asia and Pacific Region. High levels of discrimination and stigma towards key populations such as men who have sex with men (MSM) continue to exist.

Are the Philippines there yet, will they meet the Fast-track target of 90-90-90 by 2020? No, Jonas informs. In fact, targets are way off with 260 000 new HIV infections in 2016 alone.

141% increase in HIV infections was reported since 2010, particularly among key populations and young MSM. Gay men are suffering and dying in silence, fearful of accessing healthcare.

The trans gender community is diverse and have low rates of access to health and HIV services. Dr. Scheim contributed this to a number of issues including violence, legal barriers, stigma and discrimination.

As a global health agenda and key population group, the overwhelming message Dr. Scheim highlighted was the lack of inclusive research/ data in this field which mainly comes from the US.

At a clinical service level Dr. Scheim recommended thatwe need to firstly understand the basic epidemiology of the trans community and we should be asking the following questions;

-What sex where you assigned at birth?

Normal 0 false false false EN-US JA X-NONE

-Which best describes your current identity? (which can included up to 33 possible answers)

]]>liz_pearce30@hotmail.com (Elizabeth Pearce)Global issues, HIV in developing settingTue, 07 Nov 2017 11:57:56 +1100The Key to Key Populationshttp://ashm.info/global-issues-hiv-in-developing-setting/the-key-to-key-populations
http://ashm.info/global-issues-hiv-in-developing-setting/the-key-to-key-populationsThis IAS 2017 session was dedicated to addressing HIV in 4 main populations that have been identified as “key” around the world, including migrants, sex workers, men who have sex with men and people who inject drugs.The studies presented had varied countries of origin which helped to demonstrate that key populations vary worldwide.

The first presentation presented data from the aMASE study to determine the rate of migrant acquisition of HIV in Spain. This was a multi-centre cross sectional study that collected data from both patient questionnaires and clinical notes in 6 regions around Spain of patients who had been diagnosed with HIV in the preceding five years and had lived in Spain for a minimum of six months at time of diagnosis.A range of information was collected including socioeconomic, behavioural, migratory, previous HIV testing, CD4 and viral load levels and resulted in a statistical analysis to determine most likely time and place of acquisition.

Of 710 participants, there was sufficient data to estimate time of acquisition for 685.77% of the analysed respondents were men and 60% were MSM, 20% heterosexual women and 14% heterosexual men.Median age was 35 years and median time in Spain was 9 years.The region of origin were Europe 17%, Latin America 64%, Sub Saharan Africa 13% and others 6%, this trend is reflective of the large numbers of Latin American people migrating to Spain and so mirrors broader population trends.A total of 72% of the sample were estimated to have acquired HIV whilst living in Spain.Factors associated with post migratory acquisition were Latin American origin, younger age and increased duration of stay in Spain and the proportion was also higher in MSM.This highlights 2 key populations that are being failed with regards to prevention, migrants (especially Latin American) and MSM and suggests who needs targeting in national prevention strategies, such as PrEP.

The second presentation presented data collected on transactional sex in MSM from Vancouver, Canada and has been blogged about by one of my colleagues, so I will only briefly touch on this presentation as it has been covered more extensively elsewhere.The motivation for this study was to ascertain whether transactional sex in MSM is a causative factor in HIV transmission.The study objectives were to determine prevalence of transactional sex events and evaluate temporal trends and consequences such as HIV risk or acquisition in a prospective cohort study.Results of 690 participants and 8990 sexual events revealed that transactional sex was rare with 2.4% reporting receiving, 1.2% reporting giving, 0.3% reporting both giving and receiving.To assess HIV risk, the investigators focussed on condomless anal sex and HIV concordance, discordance and unknown status and there was no statistically significant difference between these groups and whether they engaged in transactional sex or not.Factors that did increase the risk of transactional sex included low income, loneliness, substance use of the partner (GHB and methamphetamine) and meeting online.

A third presentation of a study nested into France’s Ipergay study presented data about the suitability of on demand PrEP for chemsex participants.The objectives of this sub study were to better characterise chemsex participants and study the association between engagement in chemsex and PrEP use.Chemsex participants were found to be more likely to use anxiolytic medications, be sensation seeking and have increased numbers of sexual encounters.They were also more likely to have condomless anal sex, hardcore sexual practices and perceive themselves to be at higher risk of HIV.What was notable was that they were also more likely to use PrEP perhaps due to their justifiably perceived higher risk.

Fourth was a study from south Africa on health outcomes of children of female sex workers, who have about a 60% HIV prevalence rate.This was undertaken in the form of a cross sectional study at sex work venues and mobile health centres from September 2015- February 2016.The mothers completed a questionnaire and HIV testing.The children were also tested for HIV and growth parameters measured.Results demonstrated maternal HIV prevalence at 67.5% and ART at 63.6% and overall HIV prevalence in their children was 3%, rising to 4.5% in HIV positive mothers.Full vaccine coverage decreased as the children got older and 27% of children’s growth was stunted, a reflection of their nutritional status.This study really highlighted that health services for sex workers would be well placed to expand into caring for the children of their key population as well.

The Vietnamese DRIVE-IN study presented data on HIV and HCV incidence and risk in people who inject drugs in a longitudinal follow up of 204 eligible participants.Of the 204, 105 were HCV positive only, 94 were negative for both HIV and HCV and 5 were HIV positive only.No HIV seroconversions occurred during the 1 year follow up period but 18 HCV seroconversions occurred.Factors associated with HCV seroconversion included more injections and being arrested. This data supported the perception that HIV was low in this population but also brought to light that HCV needs to be addressed as a priority for this population.

Finally, data from a Kirby institute run, multi-site Opposites Attract trial presented more data to support treatment as prevention in male serodiscordant couples.A total of 358 couples enrolled worldwide and the total couple year follow up was 591 years.During this time, 3 seroconversions occurred.All 3 seroconversions reported condomless anal sex outside the principal relationship and phylogenetic analysis of the seroconverted participants and their principal partner demonstrated overwhelmingly that there were no linked transmissions.The data demonstrated that in over 12,000 acts of condomless anal sex with a virally suppressed HIV positive partner and a HIV negative partner not on PrEP, there were no transmissions of HIV.

]]>bdavidde@yahoo.com.au (Bianca Davidde)Global issues, HIV in developing settingThu, 27 Jul 2017 01:15:48 +1000Keynote speaker! Exciting start to what should be a great conference!http://ashm.info/global-issues-hiv-in-developing-setting/keynote-speaker-exciting-start-to-what-should-be-a-great-conference
http://ashm.info/global-issues-hiv-in-developing-setting/keynote-speaker-exciting-start-to-what-should-be-a-great-conferenceDr Kevin De Cock delivered an insightful keynote lecture which has set the tone for what should be a very valuable conference.

He presented the lecture titled " HIV, STIs and evolution in global health". Global health involves a a complex interplay of many different facets and although gains have been made in some areas, there is still unfinished business to contend with. These include finding a cure for HIV, vaccine development for HIV, TB and malaria and shorter answer simpler treatments for TB.

In terms of STIs there are changes and goals to be achieved. This was highlighted with the numbers of cases of syphilis, rising in the US since 2001. Of these increased numbers the majority of those affected are men, particularly MSM. Rate of congenital syphilis have risen by 35% ( did I hear that right?!) since 2013. What are we doing to decrease this burden? How did this happen? Is screening for syphilis occurring where the burden is highest?

Clearly there is no easy solution to these issues however it was concluded the forging alliances, stronger networks, deeper epidemiology and stronger science are part of the answer.

Other bloggers have written eloquently on sessions on day 1 at this meeting so I thought I might report on my impressions on the 'first 24 hours' of APACC 2017.

At conferences such as these, i am constantly reminded how lucky I am to be practising HIV Medicine in Australia, with universal healthcare and the PBS system for access to medications.

Australian clinicians and leaders in HIV Medicine (both in policy, research and mentoring) have been providing significant, and exemplary, leadership in the Asia Pacific region. This is certainly seen in the high regard and respect that is extended to Australian clinicians present at APACC. I had not realised this, but now wonder if there has been any interchange of knowledge at the 'grassroots' level of HIV care. I believe that we have a fantastic model of primary care management of HIV in Australia, and wonder if that is translatable to our regional neighbours. This may be an area for further exploration in the future, esp. as the RACGP already has associations with primary care groups in Malaysia and Hong Kong

Many Asia Pacific countries can be considered 'resource limited' in terms of support from their government/health agencies and limited access to medications eg. China's public health clinicians do not have access to INSTI's or ANY STR's. The Chinese National Free Antiretroviral Treatment Program only has access to 3TC, AZT, d4T, ddI, NVP, TDF and EFV. Most recently LPV/r was added as the 2nd line option. Contrast this to Australian clinicians who are mostly proactively getting rid of Atripla from our medical armamentarium, switching to TAF containing STRs and have access to INSTI's.

Chemsex is also an issue in Hong Kong, as it is in Australia. A poster presentation which surveyed 30 HIV positive men diagnosed recently, revealed that all had used methamphetamine in the context of sex, and 73% of participants fulfilled DSM-IV criteria for stimulant dependence syndrome.

There is a ART backbone 'turf war' going on in the region due to the rise of the concept of dual drug therapy in HIV. In their industry-sponsored symposia, arguments were put forth for maintaining a 3-drug backbone esp with TAF which is not currently in widespread use in the region vs. moving to a 2-drug regimen for naive or switch therapies which has appeal to the region ie less cost.

Where is the epidemic heading?

Chris Beyrer opened the conference with his keynote lecture entitled, HIV/AIDS in the Asia Pacific: Where is the epidemic heading?

He told us that there are 5.1 million people living with HIV in the region, this is actually a low prevalence. However, only 41% living with HIV get ARV, which means approximately 3 million of these people don't get access to ARV's. Only Australia provides adequate levels of ARV coverage.

He went on to discuss key populations, these were defined as groups who have a disproportionate burden of HIV and also lack access to services, including:

MSM (Men who have Sex with Men)

Sex workers of all genders

Trans females who have sex with men

Discordant partners

Adolescents from all key populations

He went on to tell us that the major strain of HIV has also changed within the region and that a strain predominant in Bangkok is driving the increase in HIV in the Asia Pacific area.

Health as a human right was also touched on with Chris telling us that a low proportion of PWID are receiving ARV. Despite the efficacy of HIV PrEP being proved in 2011, the roll out of this HIV prevention strategy was yet to happen.

Chris discussed how dealing with stigma and discrimination issues is a valubale tool in the fight against HIV. He highlighted how the 'war on drugs' drives PWID underground and this in turn fuels HIV/HCV rates. He drew attention to the appalling treatment of MSM as well as PWID In countries such as Indonesia and the Phillipines. In a bid to end discrimination, UNAIDS has appointed a 'SOGI' (Sexual Orientation and Gender Identity) Officer to monitor rights abuses of the LGTBIQ community. Whether this officer has any powers or impact remains to be seen.

Chris' take home message about fighting HIV in the Asia Pacific region was clear: 'MORE NEEDS TO HAPPEN IN THIS REGION'.

This was a fascinating talk that proposed an alternative model for R+D of new drugs that would reduce the cost of new drugs and improve access for all.

Love outlines how the current drug patent and monopoly for funding the R+D of new drugs has many challenges. Pharmaceutical companies invariably set prices for maximum profitability and costs have risen dramatically even over the past 10 years. The current trajectory means that high and middle-income countries will likely limit access and impose restrictions on those who receive these treatments, and resource-limited settings will face further inequities.

Love proposes an alternative model that funds R+D by “delinkage” of the cost or R+D of new drugs, from the final price of the product.Alternative funding models for R+D have been proposed; drug research grants and contracts, R+D subsidies, incentives and innovation prize funds.

Some of the above initiatives already exist. There are NIH and EU framework grants, R+D subsidies such as the Orphan Drug tax-credits which are funds available for R+D on drugs for rare diseases (apparently 47% of new US drug approvals in 2015 fell under this model).

Love proposes expansion of current incentives, and progressively switching from the current system of monopolies to alternative models of funding. Progressive delinkage mechanisms could be introduced by governments over time that sequentially move prices closer to the marginal cost of production of the drug.

Love talked about the $15 billion spent on HIV drugs in the US annually with the return of on average one new HIV drug per year. Recently Bernie Sanders in his US election campaign proposed that $3 billion of this money be set aside to fund R+D for new HIV drugs and at the same time eliminate monopolies. He also advocated setting aside funds to reward scientists and researchers who contributed to the development of a drug via open source platforms.

There seems to be growing support for Love’s model with many seeing the current system as unfair and ridiculously expensive. Apparently several members of the European parliament have expressed interest in the delinkage model, the Human Rights Council has asked states to support the principles of delinkage, India and the World Health Assembly have endorsed the model, the CEO of GSK has endorsed the delinkage model in the context of expensive drugs for rare diseases and several companies have endorsed it for the development of new antibiotics.

This issue has repercussions the world over, and is pertinent at a conference being hosted in sub-Saharan Africa that addresses the HIV and viral Hepatitis epidemics. While we come from a relatively privileged position in Australia, we do face shortages in provision of access to many of the new cancer medications, and one wonders how our health budget will fund the escalating pharmaceutical costs in the future.This talk outlined an elegant alternative model of funding R+D that would be more equitable and allow universal access to new drugs for all.

With the rapid scale up of access to ART and with countries working towards the 90-90-90 and 2030 targets, this session seemed very pertinent in addressing the final tier of the cascade – that 90% of those on treatment should have an undetectable viral load. Meg Doherty from WHO discussed that this is particularly important in settings where access to viral load and drug resistance testing is limited.

Several low and middle income countries have reported levels of HIVDR at or above 10% in ART naive patients and up to 37% in those restarting ART with prior exposure to ART. *

The WHO speaker cautioned that a “one size fits all approach” would be a mistake and this was certainly evidence by presentations from certain countries with varying resistance rates. However access to viral load, not to mind genotypic resistance testing is lacking in many low and middle income resource countries and each country needs to collect this data to guide and tailor its own response.

Modeling suggests that the cost of inaction is a costly price to pay with increased morbidity and mortality, increased transmitted resistance, increased program costs with second and third line ARVs and increases in new infection rates.

WHO recommends that each country should have a HIVDR surveillance strategy that is based on 1) Early Warning Indicators which essentially reflect the quality of care of the program and include data on prescribing practices, loss to follow-up, ARV supply continuity, viral load etc, 2) National surveys of pre-treatment resistance, 3) National surveys of acquired drug resistance, and 4) Nationally representative surveys that measure drug resistance in <18month olds.

Other interesting comments from panel members at the session emphasised the importance of monitoring drug resistance in pregnant women returning to care with PMTCT option B+ and also in children and adolescents who have lower viral load suppression rates than with adults.

The Global Fund panelist talked about the important implications of HIVDR rates in reaching other targets such as 90% of people who have need of PrEP having access to it, and HIVDR rates being important for effective PrEP.

Dr Anna Flavia presented some of the drug resistant data from Brazil where pre-treatment Efavirenz resistance rates are 7%. This has prompted discussions about whether the national program should recommend routine resistance testing prior to ART initiation, or whether the country simply switch to including Dolutegravir in the first line regimen. All cost benefit analyses favour the switch to Dolutegravir rather than performing resistance testing on all commencing treatment.

The take home message from this presentation was that drug resistance is rising and if the target of ending AIDS by 2030 is to be achieved, then monitoring and responding to HIVDR will be a critical element and that each country is called to act and collect more and better data in order to tailor their response in terms of thinking about switching ART regimens and quality improvements to their HIV programs.

*The WHO draft of the Global Action Plan on Drug Resistance (2017-2021)

President of AFAO, Dr Bridget Haire opened this session - in the absence of Dr John-Paul Sanggaran, the former Medical Officer, Christmas Island, Queensland. Bridget read extracts from a moving letter Dr John penned to highlight to governing bodies the multiple inadequacies in health management of HIV testing and treatment on Christmas island.

In it he pointed out that often an HIV test result takes at least 1-2 weeks due to logistical factors, by which time the patient has usually been "processed" and moved on to another island and so they will not receive their result in time. If the HIV result is positive then there are further problems once the patient has been tracked down, as they have been transferred to places such as Nauru where treatment access and roll-out is sub-optimal. He then described how HIV positive refugees on the island had often been placed in the "White Building" - usually reserved for people with behavioural difficulties. His experiences really highlighted the challenges faced by clinicians and patients alike, in difficult health care settings, in stark contrast to my own, well resourced Sexual Health Clinic in Sydney.

Then in the second session Dr Kathy Petoumenos presented findings from the ATRAS Study Group: The Australian HIV Observational Database Temporary Residence Access Study, of which several patients from my clinic have been gladly enrolled.

The NAPWHA group engaged various pharma companies to provide free ART to 180 medicare-ineligible patients for up to 4 years.

This study aimed to determine reasons for Medicare ineligibility, time to become eligible for HIV treatment on Medicare, and assess their long-term clinical outcomes once on ARTs. Enrolment was from 2011 - 2012. Results from the 24 month findings were presented.

Interesting results from baseline showed that 73% were male, most common visa status was Student Visa (34%) and 63% of the cohort had experienced prior ARTs (either as self-funded, trial participant, origin country or compassionate access).

Encouragingly over the period of the study, the mean CD4 count increased from a baseline of 376 to 534 at 24 months. Even more pleasing was that the percentage of patients with an undetectable viral load increased from 47% at the start of the study to a fantastic 94% at 24 months, with 100% of femalesachieving undetectable viral load.

So far 74% of participants have dropped out as they became Medicare Eligible, 17% have gone overseas and 9% were lost to follow up. Students were least likely to have stopped requiring ATRAS medications.

In the 2nd part of the presentation the group attempted to estimate cost benefit of expanding ARTS to all medicare-ineligible patients. The survey findings estimates there are approximately 450 medicare-ineligble HIV clients in Australia. After 2 years patients with a detectable viral load reduced from 53% to 6%. i.e. a 93% risk reduction in onward transmission of the infection. Thus 81 new infections would be averted/ 5 years.

Mathematical modelling using these figures shows that expanding ARTS access and treating all the temporary resident HIV+ population was determined to be at least cost-neutral - i.e. it saves as much as it costs. Of course, the public health benefit and the benefits to the HIV-supressed individuals alike is so much more than that.

Aaron Cogle (Exective Director for NAPWHA) pointed out that medicare-ineligible people are not recognised as a priority population nationally, this and other federal and state barriers to ART access need to be tackled imminently. If universal test-and-treat policy is to be realised then this population needs to be included.

Atras Ceases Nov 2015.

Sadly I was unable to attend the last presentations in this session as I had to catch my flight.

What a great conference, see you all in Adelaide (and Rio) and thanks to all or any who managed to read this far into my blog!!

]]>vhounsfield@gmail.com (Victoria Hounsfield)Global issues, HIV in developing settingSat, 19 Sep 2015 10:49:00 +1000Reflections on Australia's place in the HIV worldhttp://ashm.info/global-issues-hiv-in-developing-setting/reflections-on-australia-s-place-in-the-hiv-world
http://ashm.info/global-issues-hiv-in-developing-setting/reflections-on-australia-s-place-in-the-hiv-worldYou could almost - almost - be forgiven for feeling like the biomedical developments in HIV have come to their hump-day. Vaccines research hasn't been as successful as we had hoped, microbicides are good but not great. New drugs are refinements (and handy combinations) rather than truly novel compounds. Cure still seems so painfully far away - although there certainly has been progress announced this week - seehttps://theconversation.com/cancer-drug-promises-to-break-down-barrier-to-hiv-cure-47558 for some discussion.

We have excellent treatments, which we now know without doubt are good for patients, good for partners and good for the population. In Wednesday's morning plenary session, Mike Cohen emphasised his belief that there is now no justification for delaying therapy. Long live test and treat. Prevention studies continue to add weight to arguments for Treatment as Prevention and Pre-Exposure Prophylaxis.

The Wednesday afternoon plenary session and Friday's session on migration were reminders to step back, and consider how lucky we are in Australasia, but that this is not universal. HIV is a global disease; our 27,000 Australians living with HIV are but a tiny fraction of the 40 million people infected worldwide. People in low and middle income countries are not only living with HIV, they are still dying from it.

Clearly this isn't because there aren't treatments as our local experience shows.

People are dying because of lack of access.

In the developed world, we have has some success in fighting legal discrimination against people with HIV; this is not the case everywhere. Laws criminalising homosexuality or injecting drug use can only act as a barrier to Test and Treat. Thursday's session on Criminalisation highlighted the dangers posed by laws such as these. The HIV sector can stand tall for their efforts in fighting these laws - to improve health and to remove stigma.

An area of advocacy that, as a group, we often don't consider, however, is intellectual property and global trade. Charles Chauvel from the United Nations Development Project gave an excellent talk on the risks of IP laws for global access to medication.

Antivirals are expensive; and rather than becoming cheaper, there is a very good chance that these IP laws, coming into effect as part of free trade agreements, will limit the development and availability of generic antivirals, which are so crucial the low and middle income countries.

Australia is a world-leader in HIV research. While we look to a cure, tantalising us on the horizon, we should all remember to pause and look back, so we can make sure that no one is left behind.

]]>trentyarwood@gmail.com (Trent Yarwood)Global issues, HIV in developing settingFri, 18 Sep 2015 11:42:04 +1000Law reform to reduce HIV transmissionhttp://ashm.info/global-issues-hiv-in-developing-setting/law-reform-to-reduce-hiv-transmission
http://ashm.info/global-issues-hiv-in-developing-setting/law-reform-to-reduce-hiv-transmissionA fascinating and compelling presentation from Charles Chauvel from the a Global Comission on HIV and the Law and UNDP.

Charles spoke of the higher HIV prevalence in countries where sex work, injecting drug use and MSM are criminalised activities. He showed some graphs which clearly showed the relationship between reduction in harm reduction programs and increasing HIV. Charles gave the example of the Philippines where harm reduction services for PWID were dramatically reduced and HIV prevalence in PWID increased from 1% to over 40% in just 6 years. Although there are likely other factors at play here it is still a staggering increase.

It seems that attitudes are changing at a global level and hopefully we will see an end to the 'war on drugs' as this can hamper our efforts to reduce HIV incidence as well as access to those at risk who may need testing and treatment. We need more of a focus on drug use as a health issue and also the social issues which can contribute to problematic use.

As Charles stated in his presentation, law reform is an effective way to reduce HIV transmissions and its free!

Certified as having eliminated HIV & Syphilis transmission from mother to child.

In 2007 the WHO developed the elimination of MTCT policy - all regions have been working towards elimination. There is a structured validation process to approve and celebrate successful countries/regions. Cuba is the first country to reach this target!

Worldwide there's much work to be done - almost 1,000,000 pregnant women have HIV. Assuming a rate of 2% MTCT, there are a still a number of children diagnosed and a significant number more at risk.

]]>melissa_kelly_@hotmail.com (Melissa Kelly)Global issues, HIV in developing settingWed, 16 Sep 2015 13:55:49 +1000HIV and Women's Healthhttp://ashm.info/global-issues-hiv-in-developing-setting/hiv-and-women-s-health
http://ashm.info/global-issues-hiv-in-developing-setting/hiv-and-women-s-healthHIV and Women's Health was the topic of Wednesday morning's stream. Much interesting and varied work was presented. I will attempt to summarise below.

Damian Jeremia presented his work entitled Prevalence and Factors Associated with Modern Contraceptive use among HIV-positive women aged 15-49 years in Kilimanjaro region, Northern Tanzania.

Women's responses to a questionnaire and interview in Swahili language were aggregated. Results showed that only 54% of these women were using a form of modern contraception. Male condoms were the most common contraceptive method (25.4%). He cited lack of contraception information and lack of combined reproductive health and HIV services being the main barriers in contraception use.

Dr Lisa Noguchi presented on some complex findings from women participating in the S African-based VOICE trial. The VOICE trial is a Phase 2B trial of women using tenofavir as HIV prevention, and one of the eligibilty criteria required having effective contraception. Lisa's secondary analysis of the data looked at injectable Progestin contraception and acquisition of HSV2 Infection. Injectable progestins are the most common contraceptives used in S Africa. Whilst some data suggests hormonal contraception may increase HIV-1 risk for women, recent studies have suggested there are differences in this risk between the 2 commonly available progestin injectables - DMPA and NET-EN. Retrospective analysis of the VOICE data showed HIV-1 was higher for users of DMPA vs. NET-EN (aHR 1.41, 95% CI 1.06-1.89) p=0.02. However, the risk of HSV-2 acquisition between the 2 types of injectables turned out to be not significantly different. She noted that the data was extracted from the VOICE study retrospectively, which was originally designed to demonstrate different data and results could therefore be prone to bias.

Shaun Barnabas presented longditudinal cohort data on genital symptoms and STIs in just under 300 women aged 16-22 years in different cities of S Africa. The Cape Town cohort was more risky in behaviour with a high prevalence in STIs vs. Johannesburg, specifically a higher prevalence of chlamdyia, gonorrhoea and HSV-2. There were low rates of symptoms reported across the board,with "normal vaginal discharge" being the most common symptom (58%) and "abnormal discharge" 8% at baseline.There was little correlation between symptoms and STIs. This is an issue as S African guidelines are based on syndromic management, thus potential for under treatment is significant.

His final question was "Is it time for the SA government to move away from syndromic management?" The resounding answer from the audience response was "Yes!".

Alison Norris educated us about the gender differences in HIV testing and knowledge in Rural Malawi, one of the poorest per capita countries in the world. There were encouragingly very high rates of HIV testing in both sexes. Most powerful predictor in whether someone of either sex had ever had an HIV test was knowing the partner had received a test. Ultimately their prediction that there would be significant differences between testing and knowledge between men and women was unfounded.

A/Prof Sheona Mitchell talked on uptake of cervical cancer screening among HIV positive women participating in a pilot RCT in Uganda: the ASPIRE project (a collaborative study between Canada and Uganda). The aim of the ASPIRE project is to inform policy makers about cervical screening programs in resource poor areas.

They studied 500 women in an urban community in Kampala. Usual cervical screening involves visual pelvic speculum exam with acetic acid application.ie invasive. The potential for a less invasive test such as a self-collected swab detecting high-risk HPV strains is a novel, attractive approach for low-resource settings. HIV positive and negative women were randomised to speculum visual exam or self-collected swab.

Self collection of swabs had a high uptake in both HIV pos and neg women. It was found to highly acceptable, improved access and had high rates of retention going forward to further exam and treatment (compared to visual exam alone). She was hopeful of future POCT for the HPV swab to further reduce barriers to cervical screening uptake.

Elizabeth Fearon then finished up the session by presenting interesting data on a method to estimate the national prevalence of HIV among female sex workers in Zimbabwe by pooling data from Multiple Sampling Surveys and Programme Consultations.

My take home message from all of the above presentations is that there is much great innovative research going on in some of the most resource-stretched places on Earth. Many small steps are being made towards improving access to screening, testing, support and treatment for women (both HIV positive and negative) from these difficult to reach populations and places. But there is still a long way to go.

My apologies for not getting this blog out earlier (time travel and jet lag)

What a great conference. It has been great pleasure to meet many of the 2015 CROI ASHM bloggers.

There has been a lot of research and data looking at HIV infection and chronic systemic inflammation measured by an array of inflammatory biomarkers to predict HIV morbidity from cardiovascular disease, Neuro cognitive disease and cancers to name a few. This research has highlighted the importance of HIV infection and the risk of HIV morbidities especially in older age groups and that predictive value of traditional markers in HIV infection such as CD4 and VL must be further evaluated.

To continue on this theme of HIV morbidity; Steven Grindspoon of Massachusetts General Hospital.

This plenary session presented that the understanding of current CVD risk in HIV is limited as are treatment preventions. Chronic inflammatory biomarkers can be used as predictive markers. HIV individuals at risk of CVD risk are not identified through traditional screening pathways. We should not forget the HIV drug combination and other factors such as smoking, body fat composition, type 2 diabetes, platelet dysfunction, endothelial, renal function that contribute to CVD.

HIV immune activation relates to novel atherosclerotic phenotype in HIV. It is therefore vital to identify these individuals who may be at risk of CVD. With the current CVD risk stratification many individuals would not receive recommendation for statin treatment under current guidelines.

It is known that statins decrease CVD events in non HIV patients with low LDL and raised CRP (LDL lowering and dampening immune activation)

Newer statins do not effect glucose and less likely to have drug interactions with ARVs. Pitavastatin is primarily metabolised by glucoronidation. Minimally metabolised by CYP3A which have very little drug interaction with ARVs and no dose reduction needed

REPRIEVE a RCT, looking at Pitavastatin versus placebo in asymptomatic HIV participants with a cardiac risk score of less than 7.5

Cynthia Firnhaber presented a one year follow up cervical screening in HIV positive women in South Africa, this is significantly poignant as Cervical cancer is the highest cancer in women in Africa and responsible for 23% of all cancers. The risk of cervical cancer in HIV positive women is 3-6% higher than the general population.

In this cohort of 671 women 392, 92% were on ARVs, 80% were fully suppressed, average CD4.

Cynthia Furnhaber, University of Witswatersrand, Johannesburg, South Africa

One year follow up of HIV positive women, screen with VIA (visual inspection with acetic acid), HPV and cytology

Cervical cancer is the leading cause of death in South Africa, with the risk of developing cervical cancer in HIV cancer 3-6 times the general population. In the WHO Africa region AFRO in 2012, 250,317 died of cancer (23% cervical cancer).

837 women enrolled at baseline and 677 reviewed at one year. Characteristics such as age, CD4, VL, HPV were analysed separately.

Baseline 33% HSIL, 40%LSIL, 27% Normal a

One year follow up HSIL 7%, LSIL 70%, and Normal 23%

Average CD4 387, 87% VL< 1000, 93% ARVs

16% New HPV infection, 48% cleared HPV infection,

22% Progressed, 63% regressed via VIA

This study concluded that even HIV positive women who are on treatment have a significant risk of CIN progression and that cervical screening and access to healthcare is imperative to ensure gains in health for HIV positive women.

A eye opening plenary by Frances M Cowan, University College London, London, United Kingdom

The Price of Selling Sex: HIV Among Female Sex Workers—The Context and the Public Health Response

Globally female sex workers (FSW) are more 15% more likely to have HIV than general population. Meta-Analysis of the Burden of HIV in FSW –Asia 29% (countries not defined), Latin America 12%, Sub Saharan Africa 12% and modes of HIV transmission probably underestimate the effect of FSW in HIV transmission globally.

This talk then looked at prevention framework, legislation against violence against sex worker could reduce HIV transmission by 17-20% 0ver next decade, decrimalising sex work reduce HIV transmissions by 33-46% over the next decade.

Prevention framework should be through (individual, peers, community, public policy, and environment)

Systemic review and met analysis of 22 studies and 33,000 FSW, showed a significant reduction in HIV, STIs (Gonorrhea, Chlamydia, Syphilis) and an increase in consistent condom usage with new and regular clients. Also discussed were newer biomedical interventions such as PrEP, PEP and HIV treatment to prevent MTCT.

Conclusions

Proper inclusion of sex workers and other key populations is essential to reach 90:90:90

The Thursday Afternoon Themed discussion PEP- Remember me?

Kenneth H. Mayer

Fenway Health, Boston, MA, United States

Overview – Changes with PEP is transmission risk is one off event which needs prompt response with treatment, mostly conducted with animal studies and occupational studies, HIV transmission is relatively inefficient <1%. Guidelines are based on peer review studies. PEP guidelines vary with country to country even centre to centre.

The reports from Cambodia, Indonesia, Lao, Sri Lanka, Thailand and Vietnam all told similar sad stories - high numbers of HBV/HCV and low priority response from government.

Patients on incomes less than US$1,000 expected to pay US$14,000 for treatment!

Despite the odds, these doctors have in the past 12mths introduced new programs and are constantly advocating for greater recognition and increased funding to prevent the rise of viral hep.

Their stories may have been sad, but their drive and positive attitudes were inspiring.

]]>Christine.Janssen@sesiahs.health.nsw.gov.au (Christine Janssen)Global issues, HIV in developing settingTue, 11 Sep 2012 14:03:25 +10005 days in Washington: feathers, faith and financiershttp://ashm.info/global-issues-hiv-in-developing-setting/5-days-in-washington-feathers-faith-and-financiers
http://ashm.info/global-issues-hiv-in-developing-setting/5-days-in-washington-feathers-faith-and-financiersThe Opening Ceremony: First, a rant…there is a history to AIDS and Sunday night in Washington that history was reconstructed. It was reconstructed as one of common cause and compassion, driven by our collective faiths and heritage and the deluded notion that we have all been in this together, fighting the good fight, supporting each other in some sort of quasi evangelical quest for social justice, wherein we are blind to difference and saved by science and gods.

Every International AIDS Conference has its own local flavour, and that is appropriate; I know I am in America, a land far less cynical and irreligious than my own. But I am here, I was told, because of the fight. And I am here, I was told, because of my faith. Fighting together, fighting AIDS, fighting discrimination, fighting the naysayers who don't think treatment is prevention, who don't think we are all the same in some god's eyes. Fight on brothers and sisters! I am accompanied, I was told, by my brothers and sisters of faith, walking into the light of an AIDS free generation. An Elder of the local indigenous people waved a feather at me and a preacher called me a crusader; call me ungrateful but I resent having my motivations, my reasons for why I work in this field, presumed and attributed to someone else's idea of what makes this meaningful.

Again, I was told that I am "standing at a unique point in history", "at a defining moment". Oh, really? ... Still? ... These people have been telling me that I am standing at a unique point, 'facing a (perpetually) closing window of opportunity' for over twenty years now. When exactly is that window of opportunity going to shut? The mood of this conference would not be one of diminishing opportunity; quite the opposite, there would be more optimism of 'cure' and truly achieving an AIDS free generation than ever before. But this does not, it seems, suit the drama and theatrics of an opening night ceremony, devoted to the drama of AIDS.

The Mayor of this fair town assured me that 'AIDS knows no boundaries and crosses borders at will'. Well, yes sir, it does but the fact is it stays where it likes, stays where it meets least resistance and while it might occasionally cross into the leafy streets of Georgetown or Dupont Circle, it actually has taken up residence in your beltway and Black neighbourhoods with a vengeance that should shame you. Fact is, you have a better chance of accessing testing, getting into care and onto treatment and staying in care and on treatment in the Highlands of Papua New Guinea than you do if you are Black and gay, Black and injecting, Black and selling sex, Black and transgender, Black and any or all of the above, and you live in this city. Several presentations at this conference would show us data demonstrating this. But I digress, turns out the Mayor is "personally committed to finding a cure".
]]>edward.reis@ashm.org.au (Edward Reis)Global issues, HIV in developing settingThu, 02 Aug 2012 12:23:57 +1000